Vital Signs and the Nursing Process – Flashcards
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temperature, pulse, respirations, blood pressure and sometimes pain and oxygen saturation
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Vital signs include:
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their importance
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Vital signs are called vital because of:
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pain level or comfort level
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what is the fifth vital sign?
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identify nursing diagnoses, implement planned interventions and evaluate success when vital signs have returned to acceptable values.
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What does your assessment of vital signs allow you to do?
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vital signs
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which part of the database is obtained during assessment?
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measure your vital signs correctly, understand and interpret the values, communicate findings appropriately, and begin interventions as needed
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It is important when collecting vital signs to remember to make sure your skills include the following:
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when a patient is admitted to a facility and then as prescribed by a physician or as policy dictates
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when are vital signs take?
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on a graphic flow sheet
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where are vital signs usually charted?
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98.6 degrees farenheit
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what is the normal oral temperature?
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97 degrees to 99.6 degrees
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what is the normal range of temperature?
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environment, exercise, hormonal influences, diurnal variations, stress, ingestion of hot and cold liquids and smoking
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what factors affect body temperature?
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a rise in metabolism as occurs with exercise and digestion
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what is the primary mechanism the body uses to generate heat?
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core temperature and surface temperature
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what are the two categories of body temperature?
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temperature of the deep tissues of the body
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define core temperature
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temperature of the skin
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define surface temperature
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in the presence of pathologic disturbances and when a person is exposed to severe extremes in environmental temperature
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when is core temperature abnormal?
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temperature elevations
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what is frequently the first sign of illness?
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pyrexia, febrile and hyperthermia
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which terms all describe the condition of above normal body temperature?
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fever
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what sign is our body's defense?
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97.6 degrees
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what is a normal axillary temperature?
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99.5 degrees
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what is a normal rectal temperature?
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98.6 degrees
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what is a normal tympanic temperature?
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105 degrees
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What is the high temperature above which damage to body cells becomes possible?
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constant, intermittent or remittent
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what are the three classifications of fevers?
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when the patient becomes well
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in a remittent fever when does the temperature return to normal?
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when body temperature is abnormally low
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define hypothermia
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93.2 degrees
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Death is a risk when body temperature falls below what?
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the eardrum
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where does a tympanic thermometer measure temperature?
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axillary temperature
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what is the least accurate measurement of temperature?
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temporal artery scanner
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which method of taking temperature is appropriate in virtually all settings?
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an instrument that is placed against the patient's chest or back to hear heart and lung sounds
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define stethoscope
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the earpieces, the binaurals, the tubing and the chestpiece.
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what are the major parts of the stethoscope?
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12 to 18 inches
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how long is the proper polyvinyl tubing on a stethoscope?
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listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones
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define auscultate?
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the bell
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what part of the stethoscope transmits low pitched sounds?
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the diaphragm
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what part of the stethoscope transmits high pitched sounds?
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a rhythmic beating or vibrating movement
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define pulse
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a contraction of the heart
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each pulse beat corresponds to?
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60 and 100 beats per minute
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what is the normal adult pulse rate?
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age, sex, size, exercise, fever, acute pain, anxiety, medications, unrelieved chronic pain, hemorrhage, postural changes, metabolism and pulmonary conditions
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what are influences of pulse rate?
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pulse rate faster than 100 beats per minute
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define tachycardia
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pulse rate slower than 60 beats per minute
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define bradycardia
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any disturbance or abnormality in a normal rhythmic pattern, irregularity in the normal rhythm of the heart
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what is dysrhythmia?
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the volume refers to the amount of blood pushing against the artery wall with each beat.
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what is the volume of the pulse?
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one pulse
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every heartbeat is equal to what?
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blood goes out of the heart
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systolic pressure means
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blood goes back into the heart
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diastolic pressure means
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a pulse
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when blood leaves the heart you hear?
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swishing sound
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what is a bruit?
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supply blood to the brain
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what is the main function of the carotid artery?
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12-20
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normal respiration rate for adults is
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120/80
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normal adult blood pressure is
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60 to 100
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normal adult pulse is
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pulse deficit
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what is the difference between the apical pulse and radial pulse called?
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the hypothalamus
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what controls temperature?
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the medulla oblongata
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what controls respiration?
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problem oriented medical record
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POMR stands for
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problem oriented medical record
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What type of record does SOAPE go with?
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abnormal sounds in respiration such as crackles, rales and wheezing
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define adventitious
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2
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how many parts does a risk nursing diagnosis have?
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3
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how many parts does a regular nursing diagnosis have?
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assess the patient
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what is the first thing you do if a patient falls?
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5
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how many steps in the nursing process?
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interpersonal, technical, and intellectual
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what are different categories of nursing skills?
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assessment
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In which step in the nursing process is the database compiled?
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measurable, observable by the healthcare provider
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define objective data
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reported by the patient
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define subjective data
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the classification of a disease, injury or response based on scientific studies
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define nursing diagnosis
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the patient demonstrates signs and symptoms, an actual problem exists
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what is an actual nursing diagnosis?
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problem patient may develop, nursing actions may prevent the problem
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what is a risk nursing diagnosis?
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determined by a physician, indicates disease, illness or disorder
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what is a medical diagnosis?
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determined by the nurse, labeled with NANDA title, clinical judgment about the patient, human responses to disease or treatment
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what is a nursing diagnosis?
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NANDA label, relating to and as evidenced by
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what are the 3 parts of a nursing diagnosis?
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24
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Within how many hours of admission must a patient be assessed by law?
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when a patient enters the health care system
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when does data collection begin?
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the patient
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who is the primary source of data?
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inspection, palpation, percussion, auscultation
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what are the physical assessment techniques in order?
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results in structural change to the organ
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organic disease
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nervous or mental disease, no structural damage
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functional disease
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erythema, edema, heat, pain, purulent drainage, loss of function
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cardinal signs of inflammation
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nursing health history
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what is the initial step in the assessment process?
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OPQRSTUV method
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how do you evaluate the chief complaint?
